DEP Form 071217 "Contractor Qualification Form - Petroleum Restoration Program" - Florida

What Is DEP Form 071217?

This is a legal form that was released by the Florida Department of Environmental Protection - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Florida Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DEP Form 071217 by clicking the link below or browse more documents and templates provided by the Florida Department of Environmental Protection.

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Download DEP Form 071217 "Contractor Qualification Form - Petroleum Restoration Program" - Florida

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Rate (4.4 / 5) 11 votes
F
D
Rick Scott
lorida
epartment of
Governor
E
P
nvironmental
rotection
Carlos Lopez-Cantera
Lt. Governor
Bob Martinez Center
2600 Blair Stone Road
Noah Valenstein
Tallahassee, Florida 32399-2400
Secretary
PETROLEUM RESTORATION PROGRAM
CONTRACTOR QUALIFICATION FORM
Contractor Name: ______________________________________________ F.E.I.D. No.: ________________
Contractor Address: ________________________________________________________________________
Contact Name/Title: ________________________________________________________________________
Contact E-Mail: ________________________________________________ Contact Phone: _______________
The above contractor hereby certifies to the Florida Department of Environmental Protection (DEP) that it meets
the following requirements for contractors participating in the Petroleum Restoration Program pursuant to Rule
62-772.300, Florida Administrative Code:
Yes
No
1. Maintains all applicable certifications and professional licenses required by law (provide
valid business certificate of authorization to practice professional geology and professional
engineering or a copy of an executed contract with a another firm and their valid business
certificate of authorization and valid professional liability insurance certificate, confirm
registration with Dept. of State, confirm registration with My Florida Marketplace).
2. Complies with all applicable OSHA regulations.
Yes
No
3. Maintains Workers’ Compensation Insurance for all employees (provide valid insurance
Yes
No
certificate or documentation of exemption from Chapter 440, Florida Statutes,(F.S.).
4. Maintains Comprehensive General Liability Insurance with minimum limits of at least
Yes
No
$1 Million per occurrence and $1 Million annual aggregate for each and has named the
State as an additional insured (provide valid insurance certificate).
5. Maintains Comprehensive Automobile Liability Insurance with minimum limits of at least
Yes
No
$1 Million per occurrence and $1 Million annual aggregate for each and has named the
State as an additional insured (provide valid insurance certificate).
6. Maintains Professional Liability Insurance with minimum limits of at least $1 Million per
Yes
No
occurrence and $1 Million annual aggregate (provide valid insurance certificate).
7. Has the capacity to perform or directly supervise the majority of work at a site in
Yes
No
accordance with Section 489.113(9), Florida Statutes.
_________________________________________
___________________________________ ___________
Print Name/Title of Company Officer
Certified By (Signature)
Date
This form will be kept on file by the DEP. Contractors must immediately notify the DEP of any change in the
above criteria. The DEP may order a suspension or cessation of work for failure of a contractor to maintain their
required qualification. Please return this form to the Petroleum Restoration Program, Attn.: Contractor
Qualification Coordinator, Mail Station 4575, at the letterhead address or via email to
DWM.PRP.Contractor.Recommendations@dep.state.fl.us
Contractor Qualification Form 071217
F
D
Rick Scott
lorida
epartment of
Governor
E
P
nvironmental
rotection
Carlos Lopez-Cantera
Lt. Governor
Bob Martinez Center
2600 Blair Stone Road
Noah Valenstein
Tallahassee, Florida 32399-2400
Secretary
PETROLEUM RESTORATION PROGRAM
CONTRACTOR QUALIFICATION FORM
Contractor Name: ______________________________________________ F.E.I.D. No.: ________________
Contractor Address: ________________________________________________________________________
Contact Name/Title: ________________________________________________________________________
Contact E-Mail: ________________________________________________ Contact Phone: _______________
The above contractor hereby certifies to the Florida Department of Environmental Protection (DEP) that it meets
the following requirements for contractors participating in the Petroleum Restoration Program pursuant to Rule
62-772.300, Florida Administrative Code:
Yes
No
1. Maintains all applicable certifications and professional licenses required by law (provide
valid business certificate of authorization to practice professional geology and professional
engineering or a copy of an executed contract with a another firm and their valid business
certificate of authorization and valid professional liability insurance certificate, confirm
registration with Dept. of State, confirm registration with My Florida Marketplace).
2. Complies with all applicable OSHA regulations.
Yes
No
3. Maintains Workers’ Compensation Insurance for all employees (provide valid insurance
Yes
No
certificate or documentation of exemption from Chapter 440, Florida Statutes,(F.S.).
4. Maintains Comprehensive General Liability Insurance with minimum limits of at least
Yes
No
$1 Million per occurrence and $1 Million annual aggregate for each and has named the
State as an additional insured (provide valid insurance certificate).
5. Maintains Comprehensive Automobile Liability Insurance with minimum limits of at least
Yes
No
$1 Million per occurrence and $1 Million annual aggregate for each and has named the
State as an additional insured (provide valid insurance certificate).
6. Maintains Professional Liability Insurance with minimum limits of at least $1 Million per
Yes
No
occurrence and $1 Million annual aggregate (provide valid insurance certificate).
7. Has the capacity to perform or directly supervise the majority of work at a site in
Yes
No
accordance with Section 489.113(9), Florida Statutes.
_________________________________________
___________________________________ ___________
Print Name/Title of Company Officer
Certified By (Signature)
Date
This form will be kept on file by the DEP. Contractors must immediately notify the DEP of any change in the
above criteria. The DEP may order a suspension or cessation of work for failure of a contractor to maintain their
required qualification. Please return this form to the Petroleum Restoration Program, Attn.: Contractor
Qualification Coordinator, Mail Station 4575, at the letterhead address or via email to
DWM.PRP.Contractor.Recommendations@dep.state.fl.us
Contractor Qualification Form 071217